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W2019345340 abstract "With reduction of myocardial stress associated with ERCP in the elderly, by reducing procedure duration, utilizing preprocedure beta blockade, or by modifying sedation plans, we may reduce the number of adverse cardiopulmonary events.As the spectrum and the number of diagnostic and therapeutic GI endoscopic procedures expand, and the Western population ages, the number of complex and/or therapeutic endoscopic procedures that the elderly undergo will increase. There are few data regarding the risk of performing these procedures in elderly populations, their tolerance of these procedures, and factors predicting their outcome. Therefore, further information concerning the safety of various endoscopic procedures, especially complex procedures, in the geriatric population is important to all endoscopists.In this issue of Gastrointestinal Endoscopy, Fisher et al1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar report their prospective evaluation of cardiopulmonary complications in 130 consecutive ERCPs in 100 patients. Elevation of cardiac troponin I (cTnI) 24 hours after ERCP was used as an indicator of myocardial injury. In the population of patients over age 65 years, post-ERCP increases in cTnI occurred in 11% of subjects (6/53), 2 of whom died. One death was secondary to myocardial infarction, and the other was from dissection of an ascending aortic aneurysm. No increases in cTnI were detected in subjects under age 65 years. A significant association was also observed between the duration of ERCP and the rise in cTnI, with subjects with elevated cTnI having a mean ERCP duration of 59.5 minutes compared with 26.4 minutes in subjects without a postprocedure increase in cTnI (P = .026). In 5 of the 6 subjects with an elevated post-ERCP cTnI, the duration of the procedure exceeded 30 minutes, and, in the subjects over age 65 years, when the ERCP lasted longer than 30 minutes, cTnI elevations were observed in 5 of 29 procedures (17.2%). Linear regression analysis showed that the relative risk of myocardial injury, as detected by an elevation of cTnI, increased by 141% for each additional 15 minute duration of ERCP. Increased cTnI was not related to any comorbid condition, including total number of risk factors, arterial desaturation, hemodynamic stress, or electrocardiography (ECG) changes, although this may be from a type 2 error, given that only 6 patients had an elevation of cTnI after ERCP. The investigators conclude that although older patients tolerated ERCP well, myocardial injury as defined by an elevation of cTnI occurred in 8% of procedures (6/74). Of the various subject- and procedure-related factors evaluated, duration of ERCP was the only one found to be associated with an elevation of cTnI in older subjects.In an earlier study from our institution by Dark et al,2Dark D.S. Campbell D.R. Wesselius L.J. Arterial oxygen desaturation during gastrointestinal endoscopy.Am J Gastroenterol. 1990; 85: 1317-1321PubMed Google Scholar pulmonary function and arterial oxygen desaturation during various GI endoscopic procedures, excluding ERCP, were evaluated. Similar to Fisher et al,1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Dark et al2Dark D.S. Campbell D.R. Wesselius L.J. Arterial oxygen desaturation during gastrointestinal endoscopy.Am J Gastroenterol. 1990; 85: 1317-1321PubMed Google Scholar found that arterial oxygen desaturation correlated with both age and procedure duration.Although significant cardiopulmonary events are uncommon during endoscopic procedures, they are largely responsible for the morbidity and the mortality associated with the procedures. The reported cardiopulmonary complication rates associated with endoscopic procedures range between 5 and 308 per 100,000 procedures.3Sieg A. Hachmoeller-Eisenbach U. Eisenbach T. Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (285) Google Scholar, 4Gangi S. Saidi F. Patel K. et al.Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.Gastrointest Endosc. 2004; 60: 679-685Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar In 1 study,4Gangi S. Saidi F. Patel K. et al.Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.Gastrointest Endosc. 2004; 60: 679-685Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar patients who experienced cardiovascular complications were significantly older than patients who did not experience cardiovascular complications; whereas, in another study,5Clarke G.A. Jacobson B.C. Hammett R.J. et al.The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.Endoscopy. 2001; 33: 580-584Crossref PubMed Scopus (118) Google Scholar GI endoscopy was shown to be safe and well tolerated in an extremely elderly patient cohort (≥85 years), with a cardiopulmonary complication rate of only 0.6%.However, compared with routine endoscopic procedures of the upper- and lower-GI tract, ERCP is technically more demanding, frequently less well tolerated by patients, and is associated with much higher complication (4%-16%) and mortality (0.4%-1%) rates.6Loperfido S. Angelini G. Benedetti G. et al.Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.Gastrointest Endosc. 1998; 48: 1-10Abstract Full Text Full Text PDF PubMed Scopus (1020) Google Scholar, 7Christensen M. Matzen P. Schulze S. et al.Complications of ERCP: a prospective study.Gastrointest Endosc. 2004; 60: 721-731Abstract Full Text Full Text PDF PubMed Scopus (346) Google Scholar, 8Vandervoort J. Soetikno R.M. Tham T. et al.Risk factors for complications after performance of ERCP.Gastrointest Endosc. 2002; 56: 652-656Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar Significant cardiopulmonary complications, however, are reported relatively infrequently (0.1%-2.3%).6Loperfido S. Angelini G. Benedetti G. et al.Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.Gastrointest Endosc. 1998; 48: 1-10Abstract Full Text Full Text PDF PubMed Scopus (1020) Google Scholar, 7Christensen M. Matzen P. Schulze S. et al.Complications of ERCP: a prospective study.Gastrointest Endosc. 2004; 60: 721-731Abstract Full Text Full Text PDF PubMed Scopus (346) Google Scholar, 8Vandervoort J. Soetikno R.M. Tham T. et al.Risk factors for complications after performance of ERCP.Gastrointest Endosc. 2002; 56: 652-656Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar, 9Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (2147) Google Scholar The safety of ERCP in the elderly population has been evaluated, and complication rates are comparable with those in younger patients.5Clarke G.A. Jacobson B.C. Hammett R.J. et al.The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.Endoscopy. 2001; 33: 580-584Crossref PubMed Scopus (118) Google Scholar, 10Rodriguez-Gonzalez F.J. Naranjo-Rodriguez A. Mata-Tapia I. ERCP in patients 90 years of age and older.Gastrointest Endosc. 2003; 58: 220-225Abstract Full Text PDF PubMed Scopus (79) Google Scholar, 11Mitchell R.M. O'Connor F. Dickey W. Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older.J Clin Gastroenterol. 2003; 36: 72-74Crossref PubMed Scopus (70) Google Scholar, 12Ashton C.E. McNabb W.R. Wilkinson M.L. et al.Endoscopic retrograde cholangiopancreatography in elderly patients.Age Ageing. 1998; 27: 683-688Crossref PubMed Scopus (61) Google Scholar The safety of endoscopic sphincterotomy has also been evaluated in elderly patients, and the morbidity rate has not been shown to increase with advanced age or the general health status of patients.13Sugiyama M. Atomi Y. Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older.Gastrointest Endosc. 2000; 52: 187-191Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Similarly, in a study reported by Freeman et al,9Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (2147) Google Scholar the overall complication rate after sphincterotomy did not increase with age or the number of coexisting medical conditions. However, the deaths that did occur were almost exclusively in the elderly or very ill patients in this study. Unfortunately, given the number of subjects included in most of these studies, combined with the infrequent occurrence of significant complications, it is difficult to draw meaningful conclusions from them.The low risk of significant cardiopulmonary complications occurring during ERCP notwithstanding, some studies have confirmed that myocardial ischemia is a common event during ERCP. In most of these studies, ST-segment depression was used as a surrogate marker of myocardial ischemia and was seen during 20% to 50% of ERCPs.14Kounis N.G. Zavras G.M. Papadaki P.J. et al.Electrocardiographic changes in elderly patients during endoscopic retrograde cholangiopancreatography.Can J Gastroenterol. 2003; 17: 539-544PubMed Google Scholar, 15Johnston S.D. McKenna A. Tham T.C.K. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.Endoscopy. 2003; 35: 1039-1042Crossref PubMed Scopus (40) Google Scholar, 16Christensen M. Hendel H.W. Rasmussen V. et al.Endoscopic retrograde cholangiopancreatography causes reduced myocardial blood flow.Endoscopy. 2002; 34: 797-800Crossref PubMed Scopus (23) Google Scholar, 17Christensen M. Milland T. Rasmussen V. et al.ECG changes during endoscopic retrograde cholangiopancreatography and coronary artery disease.Scand J Gastroenterol. 2005; 40: 713-720Crossref PubMed Scopus (10) Google Scholar In one study that evaluated elderly patients (>70 years) who underwent ERCP (14), 50% of patients (15/30) developed ST-segment depression during ERCP, and one developed ST-segment elevation. Additionally, 96% of patients (29/30) experienced tachycardia during or immediately after the ERCP. Although all patients with ECG changes remained asymptomatic and the ST-segment changes resolved after the procedure was completed, a significant correlation was observed between oxygen saturation and ST-segment changes. Similarly, Johnston et al15Johnston S.D. McKenna A. Tham T.C.K. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.Endoscopy. 2003; 35: 1039-1042Crossref PubMed Scopus (40) Google Scholar found that 22% of patients (9/41) developed ST depression during ERCP. All 9 subjects also experienced episodes of sinus tachycardia, and in 7 of the patients, the ST depression became more pronounced as the heart rate increased. No correlation was observed between ST depression and age, duration of the procedure, gender, cardiac history, or pain or discomfort associated with the procedure. Furthermore, no cardiac complications were reported in these patients. Christensen et al16Christensen M. Hendel H.W. Rasmussen V. et al.Endoscopic retrograde cholangiopancreatography causes reduced myocardial blood flow.Endoscopy. 2002; 34: 797-800Crossref PubMed Scopus (23) Google Scholar performed Holter monitoring and myocardial perfusion scintigraphy at rest and during ERCP in 10 patients. Significant ST depression was observed in 2 subjects on Holter recordings obtained during the procedure. These 2 patients also demonstrated scintigraphic perfusion defects on myocardial scintigraphy when compared with images obtained at rest. None of the patients, however, experienced a cardiac complication. In another study by the same group,17Christensen M. Milland T. Rasmussen V. et al.ECG changes during endoscopic retrograde cholangiopancreatography and coronary artery disease.Scand J Gastroenterol. 2005; 40: 713-720Crossref PubMed Scopus (10) Google Scholar the investigators evaluated patients who developed ST depression during ERCP with an exercise stress test. In that study, 12/40 patients experienced ST depression during ERCP, and concomitant tachycardia was observed in 9. Ten of the 12 patients with ST depression subsequently underwent an exercise stress test, and only one had evidence of silent ischemia. In that patient, coronary angiography was performed, and there was no evidence of significant coronary artery disease. The investigators concluded that coronary vasospasm and tachycardia may have contributed to the etiopathogenesis of ST depression during ERCP.One common theme that emerges from these studies is that, although ECG changes of tachycardia and coronary ischemia occur relatively commonly during ERCP, culmination in a clinically significant adverse cardiopulmonary event is fortunately infrequent.Tachycardia during ERCP appears to be the most consistent abnormality associated with ST depression. Rosenberg et al18Rosenberg J. Overgaard H. Andersen M. et al.Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography.BMJ. 1996; 313: 258-261Crossref PubMed Scopus (47) Google Scholar undertook an intervention to test this hypothesis. They randomized 38 patients undergoing ERCP to receive either placebo or 100 mg metoprolol orally 2 hours before the procedure. Increasing evidence regarding decreased perioperative mortality in patients undergoing noncardiac surgery who receive preoperative treatment with beta-blocker therapy supports such an intervention. Ten patients who received placebo developed ECG changes of ischemia vs 1 patient who received metoprolol (P = .003). In all subjects, the episode of myocardial ischemia was associated with an increased heart rate (P = .008). The age of subjects and the duration of endoscopy were not significantly different between those who developed ischemia vs those who did not. The investigators concluded that myocardial ischemia was related to the development of tachycardia and that metoprolol lowered the heart rate sufficiently during ERCP to prevent ischemia. Although the cause of tachycardia during ERCP is likely multifactorial, including viscerocardiac reflex, endocrine stress response, side effects of medication (eg, anticholinergics), hypoxemia, and psychological stress, many of the proposed mechanisms for myocardial ischemia during endoscopy would be inhibited by beta blockade.A recently published prospective randomized trial19Riphaus A. Stergiou N. Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study.Am J Gastroenterol. 2005; 100: 1957-1963Crossref PubMed Scopus (166) Google Scholar reported that sedation with propofol was superior to midazolam/meperidine in high-risk octogenarians undergoing ERCP. In this geriatric population, subjects who received propofol were more cooperative, had shorter recovery times, had better recovery scores, and experienced significantly fewer episodes of desaturation during recovery compared with the subjects who received midazolam/meperidine.With the emergence of sophisticated imaging modalities, eg, MRCP and EUS, ERCP is evolving from a diagnostic to a therapeutic procedure. Proper patient selection after thoughtful consideration regarding available alternatives and careful and detailed evaluation of the potential risks and benefits of ERCP cannot be overemphasized. Although ERCP is safe in the elderly, with more ERCPs involving therapeutic interventions in the elderly, it is likely that these procedures will necessarily be of longer duration. Until additional data from large multicenter studies are available, the trends in the currently available literature suggest that prolonged ERCP in the elderly is at minimum associated with increased myocardial stress. One would infer that by reducing myocardial stress associated with ERCP in the elderly (eg, reducing the procedure duration, using preprocedure beta blockade, modifying sedation plans), it may be possible to reduce the number of adverse cardiopulmonary events. However, only larger studies will elucidate which factors actually positively impact on morbidity and mortality.Multiple recent studies evaluating cardiac troponin T (cTnT) levels before and after competitive marathon activities, including cycling and running, have demonstrated transient cTnT increases.20Neumayr G. Pfister R. Mitterbauer G. et al.Effect of competitive marathon cycling on plasma N-terminal pro-brain natriuretic peptide and cardiac troponin T in healthy recreational cyclists.Am J Cardiol. 2005; 96: 732-735Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 21George K. Whyte G. Stephenson C. et al.Postexercise left ventricular function and cTnT in recreational marathon runners.Med Sci Sports Exerc. 2004; 36: 1709-1715Crossref PubMed Scopus (70) Google Scholar, 22Whyte G. George K. Shave R. et al.Impact of marathon running on cardiac structure and function in recreational runners.Clin Sci (Lond). 2005; 108: 73-80Crossref PubMed Scopus (80) Google Scholar, 23Smith J.E. Garbutt G. Lopes P. et al.Effects of prolonged strenuous exercise (marathon running) on biochemical and haematological markers used in the investigation of patients in the emergency department.Br J Sports Med. 2004; 38: 292-294Crossref PubMed Scopus (112) Google Scholar, 24Shave R.E. Dawson E. Whyte P.G. et al.Cardiac troponin T in female athletes during a two-day mountain marathon.Scott Med J. 2003; 48: 41-42PubMed Google Scholar In some cases, these levels were in the myocardial infarction range, but virtually all return to the normal range within 24 hours of the event. Whether the elevated cTnT levels observed in highly trained athletes are secondary to cardiac fatigue or to minimal cardiac damage has not been conclusively established.Given the currently available literature, it is incumbent upon all endoscopists to work closely with their endoscopy teams, especially before ERCP, to assure the following: (a) maximum efficiency, (b) careful cardiopulmonary monitoring, and (c) excellent sedation in an attempt to reduce cardiopulmonary complications. Given the information reported by Fisher et al1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar in this issue of Gastrointestinal Endoscopy, this is especially important whenever a “marathon ERCP” is anticipated, especially in an elderly patient. With reduction of myocardial stress associated with ERCP in the elderly, by reducing procedure duration, utilizing preprocedure beta blockade, or by modifying sedation plans, we may reduce the number of adverse cardiopulmonary events.As the spectrum and the number of diagnostic and therapeutic GI endoscopic procedures expand, and the Western population ages, the number of complex and/or therapeutic endoscopic procedures that the elderly undergo will increase. There are few data regarding the risk of performing these procedures in elderly populations, their tolerance of these procedures, and factors predicting their outcome. Therefore, further information concerning the safety of various endoscopic procedures, especially complex procedures, in the geriatric population is important to all endoscopists. With reduction of myocardial stress associated with ERCP in the elderly, by reducing procedure duration, utilizing preprocedure beta blockade, or by modifying sedation plans, we may reduce the number of adverse cardiopulmonary events. With reduction of myocardial stress associated with ERCP in the elderly, by reducing procedure duration, utilizing preprocedure beta blockade, or by modifying sedation plans, we may reduce the number of adverse cardiopulmonary events. In this issue of Gastrointestinal Endoscopy, Fisher et al1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar report their prospective evaluation of cardiopulmonary complications in 130 consecutive ERCPs in 100 patients. Elevation of cardiac troponin I (cTnI) 24 hours after ERCP was used as an indicator of myocardial injury. In the population of patients over age 65 years, post-ERCP increases in cTnI occurred in 11% of subjects (6/53), 2 of whom died. One death was secondary to myocardial infarction, and the other was from dissection of an ascending aortic aneurysm. No increases in cTnI were detected in subjects under age 65 years. A significant association was also observed between the duration of ERCP and the rise in cTnI, with subjects with elevated cTnI having a mean ERCP duration of 59.5 minutes compared with 26.4 minutes in subjects without a postprocedure increase in cTnI (P = .026). In 5 of the 6 subjects with an elevated post-ERCP cTnI, the duration of the procedure exceeded 30 minutes, and, in the subjects over age 65 years, when the ERCP lasted longer than 30 minutes, cTnI elevations were observed in 5 of 29 procedures (17.2%). Linear regression analysis showed that the relative risk of myocardial injury, as detected by an elevation of cTnI, increased by 141% for each additional 15 minute duration of ERCP. Increased cTnI was not related to any comorbid condition, including total number of risk factors, arterial desaturation, hemodynamic stress, or electrocardiography (ECG) changes, although this may be from a type 2 error, given that only 6 patients had an elevation of cTnI after ERCP. The investigators conclude that although older patients tolerated ERCP well, myocardial injury as defined by an elevation of cTnI occurred in 8% of procedures (6/74). Of the various subject- and procedure-related factors evaluated, duration of ERCP was the only one found to be associated with an elevation of cTnI in older subjects. In an earlier study from our institution by Dark et al,2Dark D.S. Campbell D.R. Wesselius L.J. Arterial oxygen desaturation during gastrointestinal endoscopy.Am J Gastroenterol. 1990; 85: 1317-1321PubMed Google Scholar pulmonary function and arterial oxygen desaturation during various GI endoscopic procedures, excluding ERCP, were evaluated. Similar to Fisher et al,1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Dark et al2Dark D.S. Campbell D.R. Wesselius L.J. Arterial oxygen desaturation during gastrointestinal endoscopy.Am J Gastroenterol. 1990; 85: 1317-1321PubMed Google Scholar found that arterial oxygen desaturation correlated with both age and procedure duration. Although significant cardiopulmonary events are uncommon during endoscopic procedures, they are largely responsible for the morbidity and the mortality associated with the procedures. The reported cardiopulmonary complication rates associated with endoscopic procedures range between 5 and 308 per 100,000 procedures.3Sieg A. Hachmoeller-Eisenbach U. Eisenbach T. Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (285) Google Scholar, 4Gangi S. Saidi F. Patel K. et al.Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.Gastrointest Endosc. 2004; 60: 679-685Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar In 1 study,4Gangi S. Saidi F. Patel K. et al.Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.Gastrointest Endosc. 2004; 60: 679-685Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar patients who experienced cardiovascular complications were significantly older than patients who did not experience cardiovascular complications; whereas, in another study,5Clarke G.A. Jacobson B.C. Hammett R.J. et al.The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.Endoscopy. 2001; 33: 580-584Crossref PubMed Scopus (118) Google Scholar GI endoscopy was shown to be safe and well tolerated in an extremely elderly patient cohort (≥85 years), with a cardiopulmonary complication rate of only 0.6%. However, compared with routine endoscopic procedures of the upper- and lower-GI tract, ERCP is technically more demanding, frequently less well tolerated by patients, and is associated with much higher complication (4%-16%) and mortality (0.4%-1%) rates.6Loperfido S. Angelini G. Benedetti G. et al.Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.Gastrointest Endosc. 1998; 48: 1-10Abstract Full Text Full Text PDF PubMed Scopus (1020) Google Scholar, 7Christensen M. Matzen P. Schulze S. et al.Complications of ERCP: a prospective study.Gastrointest Endosc. 2004; 60: 721-731Abstract Full Text Full Text PDF PubMed Scopus (346) Google Scholar, 8Vandervoort J. Soetikno R.M. Tham T. et al.Risk factors for complications after performance of ERCP.Gastrointest Endosc. 2002; 56: 652-656Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar Significant cardiopulmonary complications, however, are reported relatively infrequently (0.1%-2.3%).6Loperfido S. Angelini G. Benedetti G. et al.Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.Gastrointest Endosc. 1998; 48: 1-10Abstract Full Text Full Text PDF PubMed Scopus (1020) Google Scholar, 7Christensen M. Matzen P. Schulze S. et al.Complications of ERCP: a prospective study.Gastrointest Endosc. 2004; 60: 721-731Abstract Full Text Full Text PDF PubMed Scopus (346) Google Scholar, 8Vandervoort J. Soetikno R.M. Tham T. et al.Risk factors for complications after performance of ERCP.Gastrointest Endosc. 2002; 56: 652-656Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar, 9Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (2147) Google Scholar The safety of ERCP in the elderly population has been evaluated, and complication rates are comparable with those in younger patients.5Clarke G.A. Jacobson B.C. Hammett R.J. et al.The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.Endoscopy. 2001; 33: 580-584Crossref PubMed Scopus (118) Google Scholar, 10Rodriguez-Gonzalez F.J. Naranjo-Rodriguez A. Mata-Tapia I. ERCP in patients 90 years of age and older.Gastrointest Endosc. 2003; 58: 220-225Abstract Full Text PDF PubMed Scopus (79) Google Scholar, 11Mitchell R.M. O'Connor F. Dickey W. Endoscopic retrograde cholangiopancreatography is safe and effective in patients 90 years of age and older.J Clin Gastroenterol. 2003; 36: 72-74Crossref PubMed Scopus (70) Google Scholar, 12Ashton C.E. McNabb W.R. Wilkinson M.L. et al.Endoscopic retrograde cholangiopancreatography in elderly patients.Age Ageing. 1998; 27: 683-688Crossref PubMed Scopus (61) Google Scholar The safety of endoscopic sphincterotomy has also been evaluated in elderly patients, and the morbidity rate has not been shown to increase with advanced age or the general health status of patients.13Sugiyama M. Atomi Y. Endoscopic sphincterotomy for bile duct stones in patients 90 years of age and older.Gastrointest Endosc. 2000; 52: 187-191Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar Similarly, in a study reported by Freeman et al,9Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (2147) Google Scholar the overall complication rate after sphincterotomy did not increase with age or the number of coexisting medical conditions. However, the deaths that did occur were almost exclusively in the elderly or very ill patients in this study. Unfortunately, given the number of subjects included in most of these studies, combined with the infrequent occurrence of significant complications, it is difficult to draw meaningful conclusions from them. The low risk of significant cardiopulmonary complications occurring during ERCP notwithstanding, some studies have confirmed that myocardial ischemia is a common event during ERCP. In most of these studies, ST-segment depression was used as a surrogate marker of myocardial ischemia and was seen during 20% to 50% of ERCPs.14Kounis N.G. Zavras G.M. Papadaki P.J. et al.Electrocardiographic changes in elderly patients during endoscopic retrograde cholangiopancreatography.Can J Gastroenterol. 2003; 17: 539-544PubMed Google Scholar, 15Johnston S.D. McKenna A. Tham T.C.K. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.Endoscopy. 2003; 35: 1039-1042Crossref PubMed Scopus (40) Google Scholar, 16Christensen M. Hendel H.W. Rasmussen V. et al.Endoscopic retrograde cholangiopancreatography causes reduced myocardial blood flow.Endoscopy. 2002; 34: 797-800Crossref PubMed Scopus (23) Google Scholar, 17Christensen M. Milland T. Rasmussen V. et al.ECG changes during endoscopic retrograde cholangiopancreatography and coronary artery disease.Scand J Gastroenterol. 2005; 40: 713-720Crossref PubMed Scopus (10) Google Scholar In one study that evaluated elderly patients (>70 years) who underwent ERCP (14), 50% of patients (15/30) developed ST-segment depression during ERCP, and one developed ST-segment elevation. Additionally, 96% of patients (29/30) experienced tachycardia during or immediately after the ERCP. Although all patients with ECG changes remained asymptomatic and the ST-segment changes resolved after the procedure was completed, a significant correlation was observed between oxygen saturation and ST-segment changes. Similarly, Johnston et al15Johnston S.D. McKenna A. Tham T.C.K. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography.Endoscopy. 2003; 35: 1039-1042Crossref PubMed Scopus (40) Google Scholar found that 22% of patients (9/41) developed ST depression during ERCP. All 9 subjects also experienced episodes of sinus tachycardia, and in 7 of the patients, the ST depression became more pronounced as the heart rate increased. No correlation was observed between ST depression and age, duration of the procedure, gender, cardiac history, or pain or discomfort associated with the procedure. Furthermore, no cardiac complications were reported in these patients. Christensen et al16Christensen M. Hendel H.W. Rasmussen V. et al.Endoscopic retrograde cholangiopancreatography causes reduced myocardial blood flow.Endoscopy. 2002; 34: 797-800Crossref PubMed Scopus (23) Google Scholar performed Holter monitoring and myocardial perfusion scintigraphy at rest and during ERCP in 10 patients. Significant ST depression was observed in 2 subjects on Holter recordings obtained during the procedure. These 2 patients also demonstrated scintigraphic perfusion defects on myocardial scintigraphy when compared with images obtained at rest. None of the patients, however, experienced a cardiac complication. In another study by the same group,17Christensen M. Milland T. Rasmussen V. et al.ECG changes during endoscopic retrograde cholangiopancreatography and coronary artery disease.Scand J Gastroenterol. 2005; 40: 713-720Crossref PubMed Scopus (10) Google Scholar the investigators evaluated patients who developed ST depression during ERCP with an exercise stress test. In that study, 12/40 patients experienced ST depression during ERCP, and concomitant tachycardia was observed in 9. Ten of the 12 patients with ST depression subsequently underwent an exercise stress test, and only one had evidence of silent ischemia. In that patient, coronary angiography was performed, and there was no evidence of significant coronary artery disease. The investigators concluded that coronary vasospasm and tachycardia may have contributed to the etiopathogenesis of ST depression during ERCP. One common theme that emerges from these studies is that, although ECG changes of tachycardia and coronary ischemia occur relatively commonly during ERCP, culmination in a clinically significant adverse cardiopulmonary event is fortunately infrequent. Tachycardia during ERCP appears to be the most consistent abnormality associated with ST depression. Rosenberg et al18Rosenberg J. Overgaard H. Andersen M. et al.Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography.BMJ. 1996; 313: 258-261Crossref PubMed Scopus (47) Google Scholar undertook an intervention to test this hypothesis. They randomized 38 patients undergoing ERCP to receive either placebo or 100 mg metoprolol orally 2 hours before the procedure. Increasing evidence regarding decreased perioperative mortality in patients undergoing noncardiac surgery who receive preoperative treatment with beta-blocker therapy supports such an intervention. Ten patients who received placebo developed ECG changes of ischemia vs 1 patient who received metoprolol (P = .003). In all subjects, the episode of myocardial ischemia was associated with an increased heart rate (P = .008). The age of subjects and the duration of endoscopy were not significantly different between those who developed ischemia vs those who did not. The investigators concluded that myocardial ischemia was related to the development of tachycardia and that metoprolol lowered the heart rate sufficiently during ERCP to prevent ischemia. Although the cause of tachycardia during ERCP is likely multifactorial, including viscerocardiac reflex, endocrine stress response, side effects of medication (eg, anticholinergics), hypoxemia, and psychological stress, many of the proposed mechanisms for myocardial ischemia during endoscopy would be inhibited by beta blockade. A recently published prospective randomized trial19Riphaus A. Stergiou N. Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study.Am J Gastroenterol. 2005; 100: 1957-1963Crossref PubMed Scopus (166) Google Scholar reported that sedation with propofol was superior to midazolam/meperidine in high-risk octogenarians undergoing ERCP. In this geriatric population, subjects who received propofol were more cooperative, had shorter recovery times, had better recovery scores, and experienced significantly fewer episodes of desaturation during recovery compared with the subjects who received midazolam/meperidine. With the emergence of sophisticated imaging modalities, eg, MRCP and EUS, ERCP is evolving from a diagnostic to a therapeutic procedure. Proper patient selection after thoughtful consideration regarding available alternatives and careful and detailed evaluation of the potential risks and benefits of ERCP cannot be overemphasized. Although ERCP is safe in the elderly, with more ERCPs involving therapeutic interventions in the elderly, it is likely that these procedures will necessarily be of longer duration. Until additional data from large multicenter studies are available, the trends in the currently available literature suggest that prolonged ERCP in the elderly is at minimum associated with increased myocardial stress. One would infer that by reducing myocardial stress associated with ERCP in the elderly (eg, reducing the procedure duration, using preprocedure beta blockade, modifying sedation plans), it may be possible to reduce the number of adverse cardiopulmonary events. However, only larger studies will elucidate which factors actually positively impact on morbidity and mortality. Multiple recent studies evaluating cardiac troponin T (cTnT) levels before and after competitive marathon activities, including cycling and running, have demonstrated transient cTnT increases.20Neumayr G. Pfister R. Mitterbauer G. et al.Effect of competitive marathon cycling on plasma N-terminal pro-brain natriuretic peptide and cardiac troponin T in healthy recreational cyclists.Am J Cardiol. 2005; 96: 732-735Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 21George K. Whyte G. Stephenson C. et al.Postexercise left ventricular function and cTnT in recreational marathon runners.Med Sci Sports Exerc. 2004; 36: 1709-1715Crossref PubMed Scopus (70) Google Scholar, 22Whyte G. George K. Shave R. et al.Impact of marathon running on cardiac structure and function in recreational runners.Clin Sci (Lond). 2005; 108: 73-80Crossref PubMed Scopus (80) Google Scholar, 23Smith J.E. Garbutt G. Lopes P. et al.Effects of prolonged strenuous exercise (marathon running) on biochemical and haematological markers used in the investigation of patients in the emergency department.Br J Sports Med. 2004; 38: 292-294Crossref PubMed Scopus (112) Google Scholar, 24Shave R.E. Dawson E. Whyte P.G. et al.Cardiac troponin T in female athletes during a two-day mountain marathon.Scott Med J. 2003; 48: 41-42PubMed Google Scholar In some cases, these levels were in the myocardial infarction range, but virtually all return to the normal range within 24 hours of the event. Whether the elevated cTnT levels observed in highly trained athletes are secondary to cardiac fatigue or to minimal cardiac damage has not been conclusively established. Given the currently available literature, it is incumbent upon all endoscopists to work closely with their endoscopy teams, especially before ERCP, to assure the following: (a) maximum efficiency, (b) careful cardiopulmonary monitoring, and (c) excellent sedation in an attempt to reduce cardiopulmonary complications. Given the information reported by Fisher et al1Fisher L. Fisher A. Thompson A. Cardiopulmonary complications of ERCP in older patients.Gastrointest Endosc. 2006; 63: 948-955Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar in this issue of Gastrointestinal Endoscopy, this is especially important whenever a “marathon ERCP” is anticipated, especially in an elderly patient." @default.
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